System and method for treating parkinson&#39;s disease and other movement disorders

ABSTRACT

Systems and methods for treating movement disorders using cortical stimulation. In one embodiment, a method for treating movement disorders comprises determining a site at the cortex of the brain of a patient related to a movement disorder of an afflicted body part. The site can be determined by obtaining a representation of neural activity occurring in the cortex of the patient and correlating an area of neural activity with the afflicted body part. The method can also include applying neural stimulation, such as electrical or magnetic waveforms, directly to the site.

CROSS-REFERENCE TO RELATED APPLICATIONS

The present application is a continuation-in-part of U.S. applicationSer. No. 09/802,808 filed on Mar. 8, 2001, and claims the benefit ofU.S. Provisional Application No. 60/432,073, both of which are hereinincorporated by reference.

TECHNICAL FIELD

The present invention is directed toward systems and methods fortreating movement disorders, such as Parkinson's Disease, that areassociated with abnormal neural activity in the brain.

BACKGROUND

A wide variety of mental and physical processes are controlled orinfluenced by neural activity in particular regions of the brain. Forexample, various physical or cognitive functions are directed oraffected by neural activity within the sensory or motor cortices. Acrossmost individuals, particular areas of the brain appear to have distinctfunctions. In the majority of people, for example, the areas of theoccipital lobes relate to vision; the regions of the left interiorfrontal lobes relate to language; portions of the cerebral cortex appearto be consistently involved with conscious awareness, memory, andintellect; and particular regions of the cerebral cortex, the basalganglia, the thalamus, and the motor cortex cooperatively interact tofacilitate motor function control.

Many problems or abnormalities with body functions can be caused bydamage, disease, and/or disorders in the brain. For example, Parkinson'sDisease (PD) is related to the degeneration or death of dopamineproducing neurons in the substantia nigra region of the basal ganglia inthe brain. Dopamine is a neurotransmitter that transmits signals betweenareas of the brain. As the neurons in the substantia nigra deteriorate,the reduction in dopamine causes abnormal neural activity that resultsin a chronic, progressive deterioration of motor function control.Conservative estimates indicate that PD may affect more than one millionindividuals in the United States alone.

PD patients typically exhibit one or more of four primary symptoms. Oneprimary symptom is a tremor in an extremity (e.g., a hand) that occurswhile the extremity is at rest. Other primary symptoms include ageneralized slowness of movement (bradykinesia); increased musclerigidity or stiffness (rigidity); and gait or balance problems (posturaldysfunction). In addition to or in lieu of these primary symptoms, PDpatients may exhibit secondary symptoms including: difficulty initiatingor resuming movements; loss of fine motor skills; lack of arm swing onthe affected side of the body while walking; foot drag on the affectedside of the body; decreased facial expression; voice and/or speechchanges; cognitive disorders; feelings of depression or anxiety; and/orother symptoms.

Effectively treating PD or other movement disorders related toneurological conditions can be very difficult. Current treatments for PDsymptoms include drugs, ablative surgical intervention, and/or neuralstimulation. Drug treatments or therapies may involve, for example, theadministration of a dopamine precursor that is converted to dopaminewithin the central nervous system (i.e., Levodopa (L-dopa)). Other typesof drug therapies are also available. Unfortunately, drug therapiesfrequently become less effective or ineffective over time for anundesirably large patient population. A PD patient may require multipledrugs in combination to extend the time period of efficacy of drugtherapies. Drug treatments additionally have a significant likelihood ofinducing undesirable physical side effects; motor function complicationssuch as uncontrollable involuntary movements (dyskinesias) are aparticularly common side effect. Furthermore, drug treatments may induceundesirable cognitive side effects such as confusion and/orhallucinations.

Ablative surgical intervention for PD typically involves the destructionof one or more neural structures within the basal ganglia or thalamusthat have become overactive because of the lack of dopamine.Unfortunately, such neural structures reside deep within the brain, andhence ablative surgical intervention is a very time consuming and highlyinvasive procedure. Potential complications associated with theprocedure include risk of hemorrhage, stroke, and/or paralysis.Moreover, because PD is a progressive disease, multiple deep brainsurgeries may be required as symptoms progressively worsen over time.Although ablative surgical intervention may improve a PD patient's motorfunction, it is not likely to completely restore normal motor function.Furthermore, since ablative surgical intervention permanently destroysneural tissue, the effects of such intervention cannot be readilyadjusted or “fine tuned” over time.

Neural stimulation treatments have shown promising results for reducingsome of the symptoms associated with PD. Neural activity is governed byelectrical impulses or “action potentials” generated in and propagatedby neurons. While in a quiescent state, a neuron is negatively polarizedand exhibits a resting membrane potential that is typically between −70and −60 mV. Through chemical connections known as synapses, any givenneuron receives excitatory and inhibitory input signals or stimuli fromother neurons. A neuron integrates the excitatory and inhibitory inputsignals it receives, and generates or fires a series of actionpotentials in the event that the integration exceeds a thresholdpotential. A neural firing threshold, for example, may be approximately−55 mV. Action potentials propagate to the neuron's synapses and arethen conveyed to other synaptically connected neurons.

Neural activity in the brain can be influenced by neural stimulation,which involves the application of electrical and/or magnetic stimuli toone or more target neural populations within a patient using a waveformgenerator or other type of device. Various neural functions can thus bepromoted or disrupted by applying an electrical current to one or moreregions of the brain. As a result, researchers have attempted to treatcertain neurological conditions, including PD, using electrical ormagnetic stimulation signals to control or affect brain functions.

Deep Brain Stimulation (DBS) is a stimulation therapy that has been usedas an alternative to drug treatments and ablative surgical therapies. InDBS, one or more electrodes are surgically implanted into the brainproximate to deep brain or subcortical neural structures. For treatingPD or other movement disorders, the electrodes are positioned in orproximate to the ventrointermediate nucleus of the thalamus; basalganglia structures such as the globus pallidus internalis (GPi); or theSubthalamic Nucleus (STN). The location of the stimulation site for theelectrodes depends upon the symptoms that a patient exhibits and theseverity of the symptoms.

In a typical DBS system, a pulse generator delivers a continuous oressentially continuous electrical stimulation signal having a pulserepetition frequency of approximately 100 Hz to each of two deep brainelectrodes. The electrodes are may be positioned bilaterally on the leftand right sides of the brain relative to particular neural structuressuch as those indicated above. U.S. Pat. No. 5,883,709 discloses oneconventional DBS system for treating movement disorders.

Although DBS therapies may significantly reduce one or more PD symptoms,particularly when combined with drug treatments, they are highlyinvasive procedures. In general, configuring a DBS system to properlyfunction within a patient requires two time consuming, highly invasivesurgical procedures for implanting the DBS electrodes. Each suchsurgical procedure has essentially the same risks as those describedabove for ablative surgical intervention. Moreover, DBS may not providerelief from some movement disorders.

Motor Cortex Stimulation (MCS) is another type of brain stimulationtreatment that has been proposed for treating Parkinson's Disease. MCSinvolves the application of stimulation signals to the motor cortex of apatient. One MCS system includes a pulse generator connected to a stripelectrode that is surgically implanted over a portion of only the motorcortex (precentral gyrus). The use of MCS to treat PD symptoms isdescribed in Canavero, Sergio, Extradural Motor Cortex Stimulation forAdvanced Parkinson's Disease: Case Report, Movement Disorders (Vol. 15,No. 1, 2000).

Because MCS involves the application of stimulation signals to surfaceregions of the brain rather than deep neural structures, electrodeimplantation procedures for MCS are significantly less invasive and timeconsuming than those for DBS. As a result, MCS may be a safer andsimpler alternative to DBS for treating PD symptoms. Present MCStechniques, however, fail to address or adequately consider a variety offactors that may enhance or optimize the extent to which a patientexperiences short term and/or long term relief from PD symptoms.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a flow chart illustrating methods for treating movementdisorders in accordance with several embodiments of the invention.

FIG. 2A is an image showing a mid saggital section of a brain of apatient.

FIG. 2B is an image showing an axial view of a portion of the cerebralcortex of the brain of the patient.

FIG. 3A is a side view of a brain of a patient with an electrode arrayimplanted in accordance with one embodiment of the invention.

FIG. 3B is a side view of a brain of a patient with an electrode arrayimplanted in accordance with another embodiment of the invention.

FIG. 3C is a lateral cross-sectional view of the cortex of a patientshowing additional stimulation sites in accordance with additionalembodiments of the invention.

FIG. 4 is a side view of a brain of a patient showing one embodiment ofapplying neural stimulation to treat movement disorders.

FIG. 5 is a cross-sectional view of the cerebral cortex of a patientillustrating another embodiment of treating movement disorders inaccordance with the invention.

FIG. 6 is a schematic view illustrating a system for treating movementdisorders in accordance with the invention.

FIGS. 7-9 are flow charts of methods in accordance with embodiments ofthe invention for treating movement disorders.

DETAILED DESCRIPTION

The following disclosure describes several embodiments and systems fortreating PD and other movement disorders using cortical stimulation.Several embodiments and features of methods and systems for treating PDin accordance with the invention are set forth and described in FIGS.1-6. Additional embodiments and features of methods and systems fortreating movement disorders, including PD, are set forth and describedin FIGS. 7-9. It will be appreciated that other embodiments inaccordance with the invention can include additional procedures ordifferent features than those shown in FIGS. 1-9. Additionally, severalembodiments of methods and systems in accordance with the invention maynot include all of the features shown in these figures. Additionally,like reference numbers refer to similar or identical components orprocedures throughout the figures.

A. Embodiments for Treating PD

FIG. 1 is a flow chart illustrating several methods for treatingmovement disorders in accordance with embodiments of the invention. Themethods shown in FIG. 1 are particularly useful for treating PD. In oneembodiment, a method 100 for treating movement disorders includes animaging procedure 102 in which an image of the relative position betweenexternal markers and at least one of the central sulcus, precentralgyrus, and/or the postcentral gyrus of a patient is provided. Theexternal markers can be anatomical features of the patient or fiducialsthat are attached to the patient. For example, the external markers canbe fiducials that are attached to the skull of the patient. The method100 also includes a site selection procedure 104 that involvesidentifying a stimulation site relative to the external markers usingthe images obtained in the imaging procedure 102. The stimulation siteis generally proximate to the dura of the patient and over at least theprecentral gyrus of the cortex. As explained in more detail below, thestimulation site can also be located over the central sulcus and/or thepostcentral gyrus of the patient. The imaging procedure 102 and the siteselection procedure 104 result in an accurate determination of thelocation of the underlying cortical features relative to externallandmarks on the patient. As explained in more detail below, this isexpected to significantly improve the efficacy of stimulation therapiesfor treating PD and other movement disorders.

The method 100 can further include a stimulating procedure 110 in whichneural stimulation is applied directly to the stimulation site. Theneural stimulation can be an electrical current applied epiduraly orsubduraly to the stimulation site. When the neural stimulation is anelectrical current applied directly to the cerebral cortex proximate tothe dura, the method 100 includes an implanting procedure 108 in whichan electrode is implanted at least proximate to the dura at thestimulation site. The implanting procedure 108 accordingly occurs afterthe site selection procedure 104 and before the stimulating procedure110. In other embodiments, the neural stimulation of the stimulatingprocedure 110 can be transcutaneous magnetic stimulation. Severalaspects of each of the procedures 102-110 are described in more detailbelow with respect to FIGS. 2A-5.

FIGS. 2A and 2B are examples of images provided by the imaging procedure102 (FIG. 1) for use in the site selection procedure 104 (FIG. 1). Theimaging procedure 102 can be Magnetic Resonance Imaging (MRI), CTimaging, fMRI imaging or other suitable processes. FIG. 2A is a magneticresonance image 200 a showing the brain 210 of a patient P along a midsaggital section. The image 200 a shows the location of various featuresof the cerebral cortex 220 relative to fiducial markers 230 attached tothe skull of the patient P. One embodiment of the site selectionprocedure 104 involves locating the pars marginalis sulcus 240 of thecortex 220 using the image 200 a of the mid saggital section. Thisparticular image is useful because the pars marginalis sulcus is theonly sulcus that can be followed into the interhemispheric fissure inthis view. Based on the location of the pars marginalis sulcus shown inimage 200 a, this position can be extrapolated to an axial image todetermine the location of the central sulcus, the postcentral gyrus, andthe precentral gyrus on the cortex 220 relative to the external markers.

The site selection procedure 104 (FIG. 1) continues with an axial imageof the cortex 220. FIG. 2B is a magnetic resonance image 200 b of abrain taken along an axial section. Referring to FIG. 2B, the parsmarginalis sulcus 240 appears as a small, symmetrical sulcus extendingbilaterally out from the interhemispheric fissure. Based upon theposition of the pars marginalis sulcus 240, the position of thepostcentral sulcus 242 can be determined by moving laterally (i.e.,outward) from the pars marginalis sulcus 240. The postcentral sulcus 242forms the posterior boundary of the postcentral gyrus 260, and thus thecentral sulcus 244 can be identified as the anterior boundary of thepostcentral gyrus 260. Similarly, the central sulcus 244 forms theposterior boundary of the precentral gyrus 250 and the precentral sulcus246 forms the anterior boundary of the precentral gyrus 250.

The site selection procedure 104 can also involve identifying anexternal region on the patient relative to the location of the centralsulcus 244. After identifying the location of the central sulcus 244 onthe image 200 b, the location of the central sulcus 244 is notedrelative to the external markers 230. Using standard neuronavigationalMRI techniques, the data from the images can be transferred into anintraoperative navigational station that locates the external positionon the scalp of the patient overlying the central sulcus 244 relative tothe position of the fiducial markers 230. The external positionaccordingly defines the general area where stimulation will be applied.The actual stimulation site is generally under the scalp at an area thatis proximate to the dura of the patient and aligned with the externalposition identified on the patient.

FIGS. 3A-3C illustrate several embodiments of the implanting procedure108 for implanting electrodes at a stimulation site. FIG. 3A, morespecifically, is a schematic side view of the brain 200 illustrating oneembodiment of implanting a linear electrode array 310 at a stimulationsite 300 a proximate to the dura and over the precentral gyrus 250. Inthis embodiment, the linear electrode array 310 has a plurality ofelectrodes 320 arranged along a single row, but in other embodiments thelinear electrode array 310 may have only one electrode 320. For example,the electrode array 310 can have only a single electrode 320 (i.e., acontact) instead of an array of electrodes. The electrodes 320 can becircular contacts each having a surface area of approximately 5 mm² andbeing spaced apart by about 7.5 mm. In other embodiments, the electrodescan be other shapes and have other configurations, such as an elongatedelectrode. The linear electrode array 310 has a lead 322 coupled to theelectrodes 320 and an implanted pulse generator implanted above the neckor at a subclavicular location. The lead 322 is tunneled through thepatient using standard techniques.

The linear electrode array 310 can be positioned so that the row ofelectrodes 320 extends in a medial to lateral direction generallyparallel with the central sulcus 244. The electrodes 320 are alsosuperimposed over the precentral gyrus 250. The linear electrode array310 generally has a plurality of electrodes 320 to provide extensivecoverage over the precentral gyrus 250 and thus activate a large numberof neurons in the motor cortex (e.g., use all of the electrodes) or onlydiscrete populations of neurons in the motor cortex with only a singleimplantation of an electrode array (e.g., activate only selectedelectrodes). The electrode array 310 can be implanted so that theelectrodes are proximate to the dura such as at an epidural or subdurallocation.

FIG. 3B is a side-view of the brain 200 illustrating another embodimentfor implanting an electrode array proximate to the dura at thestimulation site. In this embodiment, the stimulation site 300 b islocated over the precentral gyrus 250 and the postcentral gyrus 260. Agrid electrode array 330 is implanted at the stimulation site 300 bproximate to the dura. The grid electrode array 330 can include aplurality of first electrodes 340 a arranged along a first row and aplurality of second electrodes 340 b arranged along a second row. Thefirst and second rows of electrodes 340 a-b can extend generally at anoblique angle relative to the central sulcus 244. The grid electrodearray 330 also has a lead 342 coupled to the electrodes 340 a-b and animplanted pulse generator. As with the linear electrode array 310, thegrid electrode array 330 can be implanted so that the electrodes areproximate to the dura.

One aspect of several embodiments of the invention is that thestimulation sites 300 a and 300 b shown on FIGS. 3A and 3B are locatedrelative to the precentral gyrus, the central sulcus 244, and/or thepostcentral gyrus 260 using the imaging and site selection procedures102-104 described above with respect to FIGS. 2A and 2B. This enablesthe stimulation to be applied to desired locations on the cortex withmuch greater accuracy than previous methods that rely solely on theexternal anatomical features of the patient. The greater precision oflocating the stimulation sites 300 a-b for implanting the electrodearrays is expected to significantly enhance the efficacy of stimulationtreatments for treating PD and other movement disorders.

Another aspect of several embodiments is that the efficacy of thestimulation treatment can also be enhanced by locating the stimulationsites 300 a-b at a desired superior-inferior location along theprecentral gyrus and/or the postcentral gyrus relative to the sylvianfissure and the interhemispherical fissure. FIG. 3C, for example, is alateral section view taken along line 3C-3C of FIG. 3B. The stimulationsite can be located more towards the sylvian fissure 370 for treatingpredominant symptoms of speech disorders or towards theinterhemispherical fissure 380 for treating predominant symptoms of gaitdisorders. The superior-inferior location along the precentral gyrus 250and/or the postcentral gyrus 260 can accordingly be predicated by thesymptomotology of the function that is affected by the movementdisorder.

FIG. 4 is a side view illustrating several embodiments of applyingneural stimulation directly to the stimulation site. More specifically,FIG. 4 illustrates the grid electrode array 330 positioned at thestimulation site 300 b over the precentral gyrus 250, the central sulcus244, and the postcentral gyrus 260. The neural stimulation can comprisepassing an electrical current through the electrodes 340 a-b to thestimulation site 300 b. In one embodiment, the electrical current can beapplied to a single one of the electrodes 340 a or 340 b to provide amonopolar pulse of current to a small area of the cortex 220. A returnelectrode can be positioned elsewhere in the patient, such as on theother side of the patient's brain or at a subclavicular location. Thereturn electrode can be a portion of a pulse generator or anotherelectrode implanted elsewhere in the patient. In other embodiments,electrical current can be passed through all of the electrodes 340 a-bor only a subset of these electrodes to activate larger or differentpopulations of neurons. In these embodiments, the potential applied tothe electrodes 340 a-b can be the same across all of the activatedelectrodes to provide monopolar stimulation at the stimulation site.This embodiment also typically has a return electrode implantedelsewhere in the patient as explained above. In other embodiments, someof the electrodes can be biased with a positive polarity and otherelectrodes can be biased with a negative polarity. For example, thefirst electrodes 340 a can be biased with one polarity and the secondelectrodes 340 b can be biased with an opposite polarity. Thisembodiment provides a bipolar stimulation to the cortex 220. Theparticular configuration of the electrodes can be optimized afterimplantation to provide the most efficacious therapy for the patient.

The particular waveform of the stimuli depends upon the symptoms of theparticular patients. In one embodiment, the stimulus can have a waveformwith a current of approximately 0.5 mA to 10 mA, a pulse duration ofapproximately 20 microseconds-500 milliseconds, and a frequency ofapproximately 10 Hz-200 Hz. In other embodiments, the electricalstimulus can have a current of approximately 3 mA to 8 mA, a pulseduration of 100 microseconds-200 microseconds, and a frequency ofapproximately 20 Hz-50 Hz. In still other embodiments, the current canbe approximately 4 mA to 6 mA, and more particularly approximatelyaround 5 mA. The waveforms of any of the foregoing embodiments can havea voltage of approximately: 0.25 V to 5.0 V in many applications; 0.5 Vto 3.5 V in more specific applications; 2.0 V to 3.5 V in still morespecific applications; and 3.0 V in a particular application.Additionally, the pulse duration can be in the range of 90-180microseconds. The stimulus can be applied for a period of 0.5 hour-4.0hours, and in many applications the therapy is applied for a period ofapproximately 0.5 hour-1.5 hours. In other embodiments, the stimulationcan be applied continuously, or only during waking periods but notsleeping periods. Examples of specific stimulation protocols for usewith an electrode array at an epidural stimulation site over theprecentral gyrus are as follows:

EXAMPLE 1

-   -   An electrical stimulus having a current of approximately 0.1 mA        to 10 mA, an impedance of 600 to 1000 Ohms, a pulse duration of        160 microseconds, and a frequency of approximately 130 Hz. The        therapy is not applied continuously, but rather during 30-60        minute intervals.

EXAMPLE 2

-   -   The stimulus has a current of approximately 0.1 mA to 10 mA, a        pulse duration of approximately 150-180 microseconds, and a        frequency of approximately 25 Hz-31 Hz. The stimulus is applied        continuously during waking periods, but it is discontinued        during sleeping periods to conserve battery life of the        implanted pulse generator.

EXAMPLE 3

-   -   The stimulus has a current of approximately 2 mA to 4 mA, a        pulse duration of approximately 90 microseconds, and a frequency        of approximately 30 Hz. This stimulus is applied continuously        during waking and sleeping periods, but it can be discontinued        during sleeping periods.

FIG. 5 illustrates another aspect of an embodiment of the invention. Inmany cases of PD, the symptoms are manifested to a greater extent on oneside of the body than the other. For example, a patient may have atremor in both hands, but usually one hand will have a tremor worse thanthe other hand. In this embodiment, the patient's body is divided into afirst side and a second side opposite the first side relative to amedial axis (e.g., right side-left side), and only one side of thecortex is stimulated to treat the disorder on both sides of the body.This embodiment can be carried out by implanting the electrode array 320or 330 at a stimulation site on only the first side of the patient whenthe disorder of a motor function is greater on the second side of thepatient. For example, this embodiment can also include implanting one ormore electrodes at a homologous location on the contralateral hemisphererelative to the movement disorder. The single electrode array canprovide a bilateral affect that not only treats the disorder associatedwith the second side of the patient, but also treats the disorderassociated with the first side of the patient. For example, if thepatient experiences a bilateral tremor that is worse on the right sidecompared to the left side, then an electrode array can be implantedproximate to the dura over only the left hemisphere of the cortex 220.The bilateral effect of the single-side stimulation may be enhancedusing monopolar stimulation techniques in which the electrodes arebiased with the same polarity. The bilateral effect may be caused byactivation of commissural neurons (large pyramidal cells) in the deepportion of layer III of the motor cortex. Subsequent to activation,these neurons can depolarize complimentary cell groups in thecontralateral hemisphere via the corpus callosum.

In a specific embodiment, by accurately locating the electrodes over theprecentral gyrus using the imaging and site selection procedures 102 and104 described above, the electrode may maximally effect thecontralateral lower extremity musculature and also the ipsilateralmuscle groups. It is expected that the placement should be sufficientlyremote from the interhemispheric fissure to avoid venous damage orocclusion. As a result, the single-side stimulation site may beparticularly advantageous in certain situations because it requires onlya single electrode array to be planted relative to a single hemisphereof the cortex 220 of the patient. This reduces the invasiveness and therisk associated with surgery.

FIG. 5 also illustrates another embodiment in which an electrode array330 a (shown in broken line) is implanted at a site on the ipsilateralhemisphere of the brain relative to the side of the body most affectedby the movement disorder. The electrode array 330 a can be implanted byitself such that it is the only electrode array. In a differentembodiment, however, both of the electrode arrays 330 and 330 a can beimplanted at homologous and/or non-homologous regions relative to themovement disorders on both hemispheres of the brain. Additionally, theelectrode array 330 a can have only a single electrode as describedabove with respect to the electrode array 330.

FIG. 6 is a schematic view illustrating embodiments of systems fortreating movement disorders in accordance with the invention. The systemcan include the linear electrode array 310 coupled to an implanted pulsegenerator 600 a implanted at a subclavicular location in the patient P.The grid electrode array 330 can be substituted for the linear electrodearray 310. In either of these embodiments, a lead 322/342 is tunneledbetween the implanted pulse generator 600 a and the electrode array. Inanother embodiment, the system has an implanted above-neck pulsegenerator 600 b that is smaller and configured to be implanted at alocation above the neck of the patient P. The above-neck implanted pulsegenerator 600 b can be planted posteriorly of the ear of the patient P.In each of these embodiments, the electrode arrays 310 or 330 (not shownin FIG. 6) are implanted underneath the scull S of the patient P at anepidural or subdural stimulation site as set forth above.

B. Embodiment for Treating Movement Disorders

FIG. 7 is a flow chart illustrating additional methods for treatingmovement disorders in accordance with additional embodiments of theinvention. In one embodiment, a method 700 includes a site selectionprocedure 710 including determining a cortical site related to amovement disorder of an afflicted body part of the patient. In oneembodiment, the site selection procedure 710 includes obtaining arepresentation of neural activity occurring in the cortex of thepatient, and correlating an area of neural activity with the afflictedbody part. In a related embodiment, the site selection procedure 710 caninclude providing a representation of neural activity in the cortex ofthe brain of a patient, identifying a neural activation area on therepresentation considered to be related to a body part of the patientaffected by a movement disorder, and selecting the cortical site on thepatient by referencing the identified neural activation area to theanatomy of the patient.

In patients having little or no tremor symptoms, a representation ofneural activity occurring in the cortex can be obtained or provided byimaging neural activity in the cortex using a neural imaging techniquewhile performing a task related to the affected body part. For example,the representation of neural activity in the cortex can be obtained byimaging cortical neural activity while (a) the patient mentallyconcentrates on moving the affected body part, (b) the affected bodypart is moved by the patient, (c) an electrical pulse is applied to theaffected body part, and/or (d) another person or device passively movesthe affected body part. In other embodiments, obtaining a representationof neural activity in the brain can include collecting data of neuralactivity in the cortex of the patient related to the affected body partwithout necessarily generating an image. The collected data can bestored in a memory and processed to generate anatomical coordinatesand/or an image of the neural activity.

The site selection procedure 710 is expected to increase the efficacy ofthe stimulation therapy and provide additional benefits. For example,having the patient concentrate on moving the affected body part oractually move the affected body part while imaging the neural activityin the cortex is expected to provide an accurate indication of thearea(s) in the cortex where neural activity for controlling the motorfunction of the affected body part is performed. Similarly, applying anelectrical pulse to the affected body part while imaging neural activityin the cortex is expected to provide another accurate indication ofwhere neural activity occurs for controlling the motor function of theaffected body part. By providing an accurate indication of the locationof neural activity related to the affected body part, the method 700 isexpected to operate at low electrical potentials to reduce unwantedcollateral stimulation of neurons and prolong the battery life of animplanted pulse generator. Moreover, such precise location of theelectrodes enhances the efficacy of the stimulation procedure becausethe neurons that are involved in controlling the affected body part aremore likely to be stimulated in a controlled manner.

The method 700 further includes a stimulation procedure 720 thatinvolves applying neural stimulation directly to the cortical site. Thestimulation procedure can be preceded by implanting an electrode unitproximate to the dura mater at the cortical site. The electrode unit canhave a single electrode or an array with a plurality of electrodes asexplained above. The stimulation procedure 720 can include any of theelectrical waveforms set forth above. In additional embodiments, thestimulation procedure can include applying an electrical waveform havinga frequency of approximately 5-1000 Hz. In more specific embodiments,the stimulation procedure 720 can include applying an electricalwaveform having a frequency of approximately 10-60 Hz, and morespecifically at a frequency of 20 Hz or 50 Hz. Other examples could beat higher frequencies of 90-150 Hz or in a narrower range of 100-120 Hz.

FIG. 8 is a flow chart illustrating another method for treating movementdisorders in accordance with additional embodiments of the invention. Inone embodiment, the method 800 includes performing a craniotomy 810 toexpose a cortical location related to an affected body part. Thecraniotomy 810 can expose subdural or epidural tissue. The method 800further includes a test procedure 820 and a mapping procedure 830. Thetest procedure 820 includes applying a test stimulation waveform to aplurality of discrete regions of the cortical location. In oneembodiment of the test procedure 820, a single electrode is moved todifferent discrete locations of the cortical region exposed by thecraniotomy and an electrical pulse is applied to each locationseparately. In other embodiments, the test procedure 820 includesimplanting an electrode array having a plurality of electrodes such thateach electrode is adjacent to a discrete region of the corticallocation. This embodiment includes applying the test stimulationwaveform separately to one or more of the individual electrodes indifferent combinations. Both of these embodiments of the test procedure820 apply the test stimulation waveform to the discrete regions of thecortical location at separate time periods. The mapping procedure 830includes (a) verifying the proper electrode location and/or (b)measuring the efficacy of the test stimulation waveforms as they areapplied to the different discrete regions of the cortical location. Themapping procedure can occur while the patient is under an anesthetic,and it can also apply electrical pulses at a current that is sufficientto provoke a response. After verifying the electrode location duringsurgery, the mapping procedure 830 can further include monitoring thedecrease and/or increase in the tremor of a body part affected by PD asthe test waveform is applied to the different discrete regions. Themethod 800 further includes a selection procedure 840 in which one ormore of the discrete regions is selected based upon the efficacy of thediscrete regions for treating the movement disorder. The selectionprocedure 840 accordingly determines which electrode(s) receiveelectrical pulses for treating the movement disorder. The method 800,accordingly, further includes a stimulation procedure 850 includingapplying a therapy stimulation waveform to the selected regions of thecortical location.

FIG. 9 is a flow chart of another method 900 for treating movementdisorders in accordance with another embodiment of the invention. Themethod 900 includes an implanting procedure 910 in which an electrode isimplanted at a cortical stimulation site based upon a standardcorrelation between cortical neural activity and motor functions inhumans. For example, an electrode array can be implanted at a corticalstimulation site based upon the standard correlation between corticalneural activity and motor functions in humans, and in particular thestandard location for neural activity in humans for motor control of theaffected body part. The implanting procedure 910 accordingly does notnecessarily need to select the stimulation site based upon an image,data or other information to obtain or provide a representation ofneural activity in the brain related to the affected body part. Themethod 900 further includes a stimulation procedure 920 involvingapplying electrical stimulation to the cortical location to treat amovement disorder.

From the foregoing, it will be appreciated that specific embodiments ofthe invention have been described herein for purposes of illustration,but that various modifications may be made without deviating from thespirit and scope of the invention. For example, the leads of theelectrode arrays may be coupled to an external pulse generator insteadof an implanted pulse generator. In an alternate embodiment, thestimulation site can be selected at an area of the cortex that is notnormally associated with the function of the body part(s) affected bythe movement disorder (e.g., non-homologous regions). This embodimentaccordingly places the electrodes at other neurofunctional areas thatcontrol other movement and/or speech functions. In still otherembodiments, electrode arrays having different configurations ofelectrodes can be implanted on opposing hemispheres of the cortex.Furthermore, in an additional embodiment, transcutaneous magneticstimulation can be applied to the selected stimulation site beforeimplanting the electrodes to estimate the response and refine thelocation of the stimulation site. For example, a stimulation site can beselected using an imaging modality (e.g., MRI, fMFI, etc.) and/orexternally estimating the site according to the normal location forneural activity associated with the movement disorder, and thentranscutaneous magnetic stimulation can be applied at the stimulationsite and/or neighboring areas before implanting the electrode. Theprecise location for the stimulation site can then be modified accordingto the results of the transcutaneous magnetic stimulation in a mannersimilar to the mapping procedure 830 described above. Accordingly, theinvention is not limited except as by the appended claims.

1. A method for treating movement disorders, comprising: providing animage showing a relative position between an external marker on apatient and at least one of the central sulcus, the precentral gyrusand/or the postcentral gyrus of the patient; identifying a stimulationsite proximate to the dura of the patient and over the precentral gyrusrelative to the external marker; and applying neural stimulationdirectly to the stimulation site.
 2. The method of claim 1, furthercomprising implanting an electrode at the stimulation site, and whereinapplying neural stimulation comprises passing an electrical currentthrough the electrode.
 3. The method of claim 2 wherein implanting theelectrode comprises positioning an array having a plurality ofelectrodes over only the precentral gyrus of the patient.
 4. The methodof claim 2 wherein implanting the electrode comprises positioning anarray having a plurality of electrodes such that at least one electrodeis over the precentral gyrus and at least one other electrode is overthe postcentral gyrus of the patient.
 5. The method of claim 1, furthercomprising implanting an electrode array having a plurality of firstelectrodes arranged in a first row and a plurality of second electrodesarranged in a second row at the stimulation site, and wherein applyingneural stimulation comprises passing an electrical current through atleast one of the electrodes.
 6. The method of claim 5 wherein implantingthe electrode array comprises positioning the first and second rows atan oblique angle relative to the central sulcus.
 7. The method of claim5 wherein implanting the electrode array comprises positioning one ofthe first electrodes and one of the second electrodes over theprecentral gyrus of the patient, and positioning another one of thefirst electrodes and another one of the second electrodes over thepostcentral gyrus of the patient.
 8. The method of claim 1 whereinapplying neural stimulation directly to the stimulation site comprisesdelivering an electrical current directly to the dura of the patient atthe stimulation site.
 9. The method of claim 1 wherein applying neuralstimulation directly to the stimulation site comprises delivering anelectrical current directly to the patient at least proximate to thedura over the stimulation site.
 10. The method of claim 9 whereindelivering an electrical current directly to the patient comprisesapplying a unipolar electrical potential to an electrode implanted atthe stimulation site.
 11. The method of claim 9 wherein delivering anelectrical current directly to the patient comprises applying a unipolarelectrical potential to a plurality of electrodes implanted at thestimulation site.
 12. The method of claim 9 wherein delivering anelectrical current directly to the patient comprises applying a bipolarelectrical potential to a plurality of electrodes implanted at thestimulation site.
 13. The method of claim 1 wherein the patient has amovement disorder that is worse on a first side of the patient than on asecond side of the patient opposite the first side, and wherein themethod further comprises implanting an electrode over the precentralgyrus on the second side of the patient only.
 14. A method for treatingmovement disorders, comprising: locating a stimulation site at leastproximate to the dura and along the precentral gyrus of a patient byimaging at least one of the precentral gyrus, central sulcus and/orpostcentral gyrus of the patient relative to an external marker on thepatient; and applying neural stimulation directly to the stimulationsite.
 15. The method of claim 14, further comprising implanting anelectrode at the stimulation site, and wherein applying neuralstimulation comprises passing an electrical current through theelectrode.
 16. The method of claim 15 wherein implanting the electrodecomprises positioning an array having a plurality of electrodes overonly the precentral gyrus of the patient.
 17. The method of claim 15wherein implanting the electrode comprises positioning an array having aplurality of electrodes such that at least one electrode is over theprecentral gyrus and at least one other electrode is over thepostcentral gyrus of the patient.
 18. The method of claim 14, furthercomprising implanting an electrode array having a plurality of firstelectrodes arranged in a first row and a plurality of second electrodesarranged in a second row at the stimulation site, and wherein applyingneural stimulation comprises passing an electrical current through atleast one of the electrodes.
 19. The method of claim 18 whereinimplanting the electrode array comprises positioning the first andsecond rows at an oblique angle relative to the central sulcus.
 20. Themethod of claim 18 wherein implanting the electrode array comprisespositioning one of the first electrodes and one of the second electrodesover the precentral gyrus of the patient, and positioning another one ofthe first electrodes and another one of the second electrodes over thepostcentral gyrus of the patient.
 21. The method of claim 14 whereinapplying neural stimulation directly to the stimulation site comprisesdelivering an electrical current directly to the dura of the patient atthe stimulation site.
 22. The method of claim 14 wherein applying neuralstimulation directly to the stimulation site comprises delivering anelectrical current directly to the patient at least proximate to thedura over the stimulation site.
 23. The method of claim 22 whereindelivering an electrical current directly to the patient comprisesapplying a unipolar electrical potential to an electrode implanted atthe stimulation site.
 24. The method of claim 22 wherein delivering anelectrical current directly to the patient comprises applying a unipolarelectrical potential to a plurality of electrodes implanted at thestimulation site.
 25. The method of claim 22 wherein delivering anelectrical current directly to the patient comprises applying a bipolarelectrical potential to a plurality of electrodes implanted at thestimulation site.
 26. The method of claim 14 wherein the patient has amovement disorder that is worse on a first side of the patient than on asecond side of the patient opposite the first side, and wherein themethod further comprises implanting an electrode over the precentralgyrus on the second side of the patient only. 27-46. (canceled)
 47. Amethod for treating movement disorders, comprising: determining a siteat the cortex of the brain of a patient related to a movement disorderof an afflicted body part by obtaining a representation of neuralactivity occurring in the cortex of the patient and correlating an areaof neural activity with the afflicted body part; and applying neuralstimulation directly to the site.
 48. The method of claim 47, furthercomprising implanting an electrode proximate to the dura mater at thesite, and wherein applying neural stimulation to the site compriseselectrically biasing the electrode.
 49. The method of claim 47 whereinobtaining a representation of neural activity occurring in the cortexcomprises imaging neural activity in the cortex using a neural imagingtechnique while the patient mentally concentrates on moving theafflicted body part.
 50. The method of claim 47 wherein obtaining arepresentation of neural activity occurring in the cortex comprisesimaging neural activity in the cortex using a neural imaging techniquewhile the patient moves the afflicted body part.
 51. The method of claim47 wherein obtaining a representation of neural activity occurring inthe cortex comprises imaging neural activity in the cortex using aneural imaging technique while applying an electrical pulse to theafflicted body part.
 52. The method of claim 47 wherein obtaining arepresentation of neural activity occurring in the cortex comprisesimaging neural activity in the cortex using a neural imaging techniquewhile an entity other than the patient passively moves the afflictedbody part.
 53. The method of claim 47 further comprising implanting anelectrode proximate to the dura mater at the site, and wherein applyingneural stimulation to the site comprises applying an electrical waveformhaving a frequency of approximately 50-500 Hz.
 54. The method of claim47 further comprising implanting an electrode proximate to the duramater at the site, and wherein applying neural stimulation to the sitecomprises applying an electrical waveform having a frequency ofapproximately 90-130 Hz.
 55. The method of claim 47 further comprisingimplanting an electrode proximate to the dura mater at the site, andwherein applying neural stimulation to the site comprises applying anelectrical waveform having a frequency of approximately 100 Hz.
 56. Themethod of claim 47 further comprising implanting an electrode proximateto the dura mater at the site, and wherein applying neural stimulationto the site comprises applying an electrical waveform having a frequencyof approximately 120 Hz.
 57. A method of treating movement disorders,comprising: providing a representation of neural activity in the cortexof the brain of a patient; identifying an area of neural activation onthe representation expected to be related to a body part of the patientaffected by a movement disorder; selecting a stimulation site on thepatient by referencing the identified area of neural activation to theanatomy of the brain of the patient; and applying electrical stimulationto the cortex of the patient at the stimulation site.
 58. The method ofclaim 57 wherein providing a representation of neural activity andidentifying an area of neural activity related to the affected body partcomprises imaging neural activity in the cortex using a neural imagingtechnique while the patient mentally concentrates on moving the affectedbody part and noting an area on the image reacting to the mentalconcentration of the patient.
 59. The method of claim 57 whereinproviding a representation of neural activity and identifying an area ofneural activity related to the affected body part comprises imagingneural activity in the cortex using a neural imaging technique while thepatient moves the affected body part and noting an area on the imagereacting to the movement of the affected body part.
 60. The method ofclaim 57 wherein providing a representation of neural activity andidentifying an area of neural activity related to the affected body partcomprises imaging neural activity in the cortex using a neural imagingtechnique while applying an electrical pulse to the affected body partand noting an area on the image reacting to the electrical pulse appliedto the affected body part.
 61. The method of claim 57 wherein providinga representation of neural activity and identifying an area of neuralactivity related to the affected body part comprises imaging neuralactivity in the cortex using a neural imaging technique while an entityother than the patient passively moves the affected body part and notingan area on the image reacting to movement of the affected body part.62-65. (canceled)